The American Experience with TB Elimination

Transcription

1 Reaching the Goal of TB Elimination by 2035 March 3, 2015 The American Experience with TB Elimination John Jereb, M.D. Medical officer Division of Tuberculosis Elimination National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention Overview of Presentation History BCG, or treatment of latent M. tuberculosis infection? Epidemiologic trends Strategy going forward

2 Leading Causes of Death in the United States, 1900, 2010 Jones, DS, et al., N Engl J Med Jun 21;366(25): CONSUMPTION PRIMARILY A NERVE DISEASE Read before the Illinois State Medical Society, May, BY J. J. M. ANGEAR, B. S.,M.A.,M.D., Professor of Physiology, Nervous and Mental Disease in College of Physicians and Surgeons, Keokuk, Iowa. Professor of Physiology and Pathology in United States Dental College Surgeon of the Columbian Accident Company Attending Physician National Temperance Hospital Member American Medical Association Illinois State Medical Society Chicago Medical Society Chicago Pathological Society Chicago Academy of Sciences Ex-Preside J. J. M. ANGEAR, B.S.,M.A.,M.D JAMA. 1893;XX(20):

3 New York City TB Surveillance Biggs, The Administrative Control of Tuberculosis, 1907 TB Death Rate, Mantoux Skin Test Influenza Epidemic Hundreds 1 Mortality Rate First Morbidity Surveillance 0

4 Framingham Demonstration Study, st medical survey of an entire population Many children tuberculin tested Radiograph first systematically used as a diagnostic tool Expert consultation made available to local practitioners Sevenfold increase in the number of cases reported in 1 year National Tuberculosis Christmas Seal Program Establish state societies Secure TB divisions in local health depts. Education Employment of nurses to conduct surveys Operation of clinics, dispensaries Financial aid for patients in institutions Relief for families and patients Source: The History of Medicine Division. Prints and Photographs Collection. 31 January <

5 Source: The History of Medicine Division. Prints and Photographs Collection. 31 January < U.S. Library of Congress Website: Available at

6 U.S. Library of Congress Website: Available at U.S. Library of Congress Website: Available at

7 TB Case Rates and Death Rate, Antibiotic Era Case Rate (Active/Inactive) 1979 Case-based reporting 1993 Expanded casebased reporting TB Resurgence 60 Mortality Rate 40 Case Rate (Active Only) Federal TB Program USPHS 0

8 Incidence of Tuberculosis among Initial Reactors to Tuberculin Puerto Rico, Comstock GW, Livesay VT, Woolpert SF: The Prognosis of positive tuberculin reaction in childhood and adolescence. Am J Epidemiol 99:134, 1974 Clinical Studies of Treatment of Latent M. tuberculosis Infection 1952 INH is introduced 1954 Lincoln (Bellevue Hosp, NYC) notes that children with TB treated with INH do not develop meningitis 1955 USPHS cooperative study of the effects of INH on primary TB in children Controlled chemoprophylaxis trials (12 trials; 7 countries; 100,000 participants) 1970 IUAT trial among persons with fibrotic lesions (7 European countries; 28,000 participants) 1992 Controlled trial of three regimens among persons with silicosis (Hong Kong; 679 participants) TB prevention trials among persons with HIV infection (7 trials; 7 countries; 7,000 participants; included SCMD regimens)

9 U.S.: Treatment for TB Prevention 1965 ATS recommends INH preventive therapy for persons with Evidence of old, healed, untreated TB Recent tuberculin skin test (TST) conversion < 3 years of age with TST positive result 1967 Extend to all with TST 10 mm 1974 Exclude persons > 35 years of age 1983 Add clinical and laboratory monitoring 1998 Test high risk groups 2000 Targeted Testing month, 12-dose DOT combination regimen ARPE Report, United States, Investigation of Sputum AFB Smear Positive TB (data as of 2/1/2013) Year Jurisdictions Reporting (N) Cases for investigation (N) Cases with No Contacts (N) Contacts Identified (N) Contacts Evaluated (N) TB Disease (N) Latent TB Infection (N) Started LTBI Treatment (N) Completed LTBI Treatment (N)

10 ARPE Report, United States, Investigation of Sputum AFB Smear Positive TB (data as of 2/1/2013) Year Jurisdictions Reporting (%) Contacts Identified (%) No Contacts Identified (%) Contact per Case (N, avg.) Contacts Evaluated (%) TB Disease Rate (%) Latent TB Infection (%) LTBI Treatment Initiated (%) LTBI Treatment Completed (%) Cumulative TB Rate 33 months from enrollment MITT Sterling et al. Log-rank P-value: 0.06

11 Tolerability MITT population Outcome Treatment completion Permanent drug d/cany reason 9H 3HP P-value N=3,745 N=3,986 2,585 (69.0%) 3,362 (82.0%) < ,160 (31.0%) 624 (18.0%) < Permanent drug d/cdue to an adverse 135 (3.6%) 188 (4.7%) event Death 39 (1.0%) 31 (0.8%) ,000 Reported TB Cases United States, * 25,000 No. of Cases 20,000 15,000 10,000 5,000 0 *Updated as of June 11, Year

12 TB Case Rates,* United States, 2013 D.C. < 3.0 (2013 national average) *Cases per 100,000. **Information as of June 11, 2014 >3.0 TB Hot Topics, from Surveillance Foreign born Homelessness Incarceration HIV/AIDS Completion of Therapy

13 The 22 TB High Burden Countries, 2013 Afghanistan Bangladesh Brazil Cambodia China DRC Ethiopia India Indonesia Kenya Mozambique Myanmar/Burma Nigeria Pakistan Philippines Russian Federation South Africa Tanzania Thailand Uganda Viet Nam Zimbabwe Division of Tuberculosis Elimination National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Top 10 Countries of Birth of Foreign-born Persons Reported with TB, United States, Mexico 2. Philippines 3. India 4. Viet Nam 5. China 6. Guatemala 7. Haiti 8. Ethiopia 9. Honduras 10.Myanmar Division of Tuberculosis Elimination National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

14 19,000 Number of TB Cases in U.S.-born vs. Foreign-born Persons United States, * 17,000 15,000 13,000 No. of Cases 11,000 9,000 7,000 5,000 3,000 1,000-1,000 U.S.-born Foreign-born *Updated as of June 11, No. of Cases Trends in TB Cases in Foreign-born Persons United States, * Percentage 9, ,000 7,000 6,000 5,000 4,000 3,000 2,000 1, Number of Cases Percentage of Total Cases *Updated as of June 11, 2014.

15 Percentage of TB Cases Among Foreign-born Persons, United States* DC DC *Updated as of June 11, >50% 25% 49% <25% TB Cases Reported as Homeless in the 12 Months Prior to Diagnosis, Age 15, United States, * 1,600 1,400 1,200 1, % 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% Number of Cases Percent of Total Cases *Updated as of June 11, Note: Homeless within past 12 months of TB diagnosis

16 TB Cases by Residence in Correctional Facilities, Age 15, United States, * 1,200 1, % 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% Number of Cases Percent of Total Cases *Updated as of June 11, Note: Resident of correctional facility at time of TB diagnosis Estimated HIV Coinfection in Persons Reported with TB, United States, * % Coinfection Years Old All Ages *Updated as of June 11, Note: Minimum estimates based on reported HIV-positive status among all TB cases in the age group

17 Percentage Completion of TB Therapy United States, * Completed in one year or less Completed * Updated as of June 11, Data available through 2011 only. Note: Includes persons alive at diagnosis, with initial drug regimen of one or more drugs prescribed, who did not die during therapy. Excludes persons with initial isolate rifampin resistant, or patient with meningeal disease, or pediatric patient (aged <15) with miliary disease or positive blood culture. Framework: Elements of National Elimination Strategy Ending Neglect: The Elimination of Tuberculosis in the United States Institute of Medicine Report published in 2000 CDC response includes 6 goals that are elements of elimination strategy in United States

18 Goal I: Maintain Control 5 components: detection of TB cases; treatment of TB cases; investigation of contacts; treatment of infected contacts; infection control Importance of oversight and support by health department to ensure patients complete treatment DOT and incentives and enablers: effective, but resource intensive and difficult to sustain Alternatives, e.g., video or e-dot Loss of expert personnel, especially experienced public health nurses Goal II: Accelerate the Decline 3 components: addressing LTBI; regionalizing; genotyping and outbreak detection and response Genotyping is useful, but different applications based on incidence Low incidence not as valuable for outbreak detection, may be more useful for detecting false positives Methods with better resolution needed in some situations (WGS) Insufficient surge capacity to respond to outbreaks

19 Latent M. tuberculosis infection (LTBI) Problem is vast, and a major initiatives are needed Registry and a surveillance system Scale up of testing to targeted populations More focused guidance on who to target Eliminate wasteful testing of low-risk persons Specific funding for IGRAs, especially for foreign-born Scale up of short course LTBI treatment (3HP, 4R) Communication, outreach Engagement of affected communities and their medical providers Goal III: New tools Shorter treatment regimens for TB and LTBI Point-of-care diagnostics LTBI test that predicts who will get TB disease Vaccine

20 Goal IV: Global TB Focus on screening of immigrants in the United States Overseas priorities Expansion of screening for TB disease to populations beyond permanent immigrants and refugees Addition of LTBI testing and treatment to current overseas screening program Goal V: Mobilize and Sustain Support Need better messages simple, clear and memorable Need more active champions and advocates Focus on the affected communities

21 Goal VI: Track Progress Use standard national indicators Sometimes not as relevant to low-incidence states Flexible program evaluation Thank You! Questions?

22 TB Case Rates by Age Group and Sex, United States, 2013* Cases per 100, Under Male Female *Updated as of June 11, TB Case Rates by Race/Ethnicity* United States, ** Cases per 100, White Asian Native Hawaiian or Other Pacific Islander *All races are non-hispanic. **Updated as of June 11, American Indian or Alaska Native Black or African American Hispanic or Latino

23 Reported TB Cases by Race/Ethnicity* United States, 2013 Hispanic or Latino 29% Black or African American 22% American Indian or Alaska Native 1% Native Hawaiian or Other Pacific Islander 1% White 15% Asian 32%. *All races are non-hispanic. Persons reporting two or more races accounted for less than 2% of all cases Budget Appropriated FY 2014: $142,256,000 Appropriated FY 2015: $142,256,000 Ceiling FY 2014: $138,721,979 Ceiling FY 2015: $138,729,667 Level funding